IDEATORY APRAXIA IN A LEFT-HANDED PATIENT
WITH RIGHT-SIDED BRAIN LESION
Klaus Poeck and Gerd Lehmkuhl
(Abteilung Neurologie, RWTH, Aachen, West-Germany)

INTRODUCTION

The syndrome of idea tory apraxia is not uniformly described in the
literature. There is general agreement that the diagnosis of ideatory apraxia
is made when a patient exhibits faulty use of objects, and when this is due
neither to a paralysis, sensory disturbance, lack of understanding of the
task nor of recognition of the object, nor overall mental confusion. This
last requirement holds true even though the first case reports, in particular
those by Pick (1905), described patients who had diffuse brain damage and
severe overall intellectual deficit.
Two opposed positions, however, are maintained in the literature with
regard to the general motor setting where the faulty use of objects appears.
Liepmann (1905, 1908) considered ideatory apraxia as an "Apraxie der
Handlungsfolgen". For him the syndrome was a disturbance in the performance of complex actions involving the serial ordering of simple movements, which, in isolation, could be executed correctly. Along the same
line Hecaen (1968) described ideatory apraxia as "an impairment of the
logical and harmonious sequence of the several elementary movements that
make up a complex act, though each movement by itself is executed
correctly" .
In sharp contrast, Morlaas (1928) advocated the view that the failure
in complex serial motor actions was not crucial for the diagnosis of ideatory
apraxia, and that the distinctive feature of the syndrom,~ , was a disturbance
in the use of real objects, in simple as well as in complex serial movements.
This view was adopted, among others, by De Renzi, Pieczuro and Vignolo
(1968). The three cases described by Heilmann (1973) fall in neither
category since their motor impairment was confined to pantomime, whereas
the handling of real objects was intact.
Idea tory apraxia is considerably rarer than ideomotor apraxia. Hecaen
(1968) found that ideomotor apraxia is six times more frequent than
Cortex (1980) 16, 273-284.

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Klaus Poeck and Gerd Lehmkuhl

ideatory apraxia. It is obvious that in research based on the definition of
Morlaas a larger number of patients with ideatory apraxia is likely to be
detected among a given population of brain damaged patients than in
research based on Liepmann's concept. For instance, De Renzi, Pieczuro
and Vignolo (1968) found idea tory apraxia in 28 % of their left brain
damaged patients. In contrast, Ajuriaguerra, Hecaen and Angelergues (1960)
found the syndrome in only 4,7% of their left brain damaged patients.
With regard to the localization of the brain lesion, Pick (1905) had
initially considered ideatory apraxia as a symptom of diffuse brain damage
and this view was reiterated by Nielsen (1936) and Denny-Brown (1968).
Later, Liepmann (1908) regarded the syndrome, like ideomotor apraxia,
as the consequence of a circumscribed lesion in the hemisphere dominant
for language. To-day there is general agreement that ideatory apraxia is one
of the classical syndromes of damage to the left hemisphere, in particular
to its posterior portions (Hecaen, 1960, 1968; Kimura and Archibald,
1974; Hecaen and Albert, 1978). Most authors (e.g. Alajouanine and
Lhermitte, 1963) feel that the underlying brain lesion is quite extensive. To
our knowledge, no case has been described in the literature where ideatory
apraxia was brought about by a focal right-sided brain lesion in a lefthander.
This raises the question of whether aphasia and ideomotor apraxia have
an influence on the syndrome of ideatory apraxia. There is little agreement
in the literature on the question of whether these three left hemispheric
syndromes occur in close association (Nathan, 1947) or in relative independence (Hecaen, 1968; De Renzi et aI., 1968). These problems are discussed
extensively in Hecaen and Albert (1978).
The current state of affairs makes it desirable to publish well documented
cases in which the syndrome of ideatory apraxia can be observed unequivocally and in which it is possible to ascertain the locus of the brain lesion
as well as to determine the possible relation of the syndrome with aphasia
and ideomotor apraxia. We want to discuss a case of ideatory apraxia in
a left-handed patient with a right-sided brain lesion and a merely transient
aphasia, but a persisting ideatory apraxia after the initial ideomotor apraxia
had cleared. For reasons discussed in detail by Poeck (1978) we are going
to follow the definition that ideatory apraxia is a disturbance in the motor
organisation of a complex situation, requiring a series of movements, where
the handling of actual objects is involved (Poeck and Lehmkuhl, 1980).

CASE REPORT

H.G., a sixty-nine-year old left-handed housewife, was admitted to our department on March 17th, 1978,oecatise-a rapidly expanding, space occupying

Ideatory apraxia in a left-handed pqtient

275

intracranial lesion was suspected. Personal and family history were unremarkable.
The evening prior to admission her husband found her confused and disorientated. She went to bed at about 10 in the evening. In the morning she was not
able to get up, she talked very little and complained of a headache. During the
following hours she became increasingly drowsy. On admission the patient was
found somnolent; she was not co-operative and hardly reacted to questions and
commands. Movements with the left arm and leg were reduced. She had a leftsided hemianopia.
The EEG showed a sleep pattern with a focal abnormality in the theta-delta
range in the right basal temporal area. Computerized cranial axial tomography
on the day of admission showed a marked impression of the right cella media
and a slight displacement of the ventricular system to the left (Figure 1 A, B).
There was hemorrhage located in the area of the posterior part of the sylvian
fissure. about 4 em in diameter and surrounded by an area of edema about 1
em in diameter.
Following the day of admission the patient was still somnolent, disorientated,
and she had a left-sided hemiparesis. Three days later a carotid angiography
was performed. It did not reveal the source of the hemorrhage.
The patient's condition improved rapidly, so that she could move her left
arm. She was, however, still disorientated. These symptoms cleared during the
following days. A control CT (Figure 1 C, D) on March 30th, that is two weeks
after admission, showed that the area of hemorrhage had diminished whereas
the surrounding edematous area had increased. There was still a displacement
of the ventricular system. The EEG now showed an irregular alpha rhythm, with
delta activity over the entire right hemisphere.

NEUROPSYCHOLOGICAL FINDINGS

During the first days of hospitalization the patient had an aphasia of
the Wernicke type. She spoke fluently with many semantic paraphasias.
The structure of the sentences was paragrammatic, comprehension impaired. In naming tasks she made numerous errors. The aphasia improved
over a period of about ten days. At this time the patient showed little
initiative and had to be repeatedly encouraged to carry out the requested tasks.

Formal aphasia examination on .April 6th
In her overall communicative behaviour the patient showed no discernible difficulties (Goodglass-Kaplan severity score of 4). The semantic
and syntactic structure of her spontaneous speech production was only
slighty impaired; phonemic errors did not occur. However the patient's
speech did contain a number of stereotyped utterances. On the Token Test
the patient achieved 7 points (corrected value, Orgass 1976a, 1976b),
indicating only a very mild language disorder.

Klaus Poeck and Gerd Lehmkuhl

276

The patient was able to repeat isolated phonemes, monosyllabic words,
compound nouns and sentences correctly.

A

'8

c

o

Fig. 1 - Computerized axial tomography 0/ patient H. G.
A, B: 17.3.78, note large area 0/ hemorrhage at the level 0/ the posterior part 0/ sylvian fissure, surrounded by edema. For details see text. C, D: 2 weeks after admission.

Ideatdry apraxia in a left-handed patient

277

In a naming task she identified 22 out of 30 depicted objects, 27 of
30 colours were identified. In describing pictures the patient showed the
same degree of impairment as when naming objects (18/30). The patient's comprehension for written words (23/30) was somewhat better
than her auditory comprehension for words (19/30), however no difference was found between her comprehension for written and spoken sentences (18/30). In reading words and sentences aloud no paralexias could
be observed. But when writing words and sentences on dictation many paragraphias were observed (24/120). The patient failed to put together
block letters in response to dictated words and sentences. As usual, this
aphasia due to a space occupying lesion could not be classified as a belonging to one of the major vascular aphasic syndromes.

Testing for intelligence on April 17th
The Performance IQ in the German version of the Wechsler Intelligence Test was 74. In all subtests the patient rated considerably below
normal, whereas she was able to describe satisfactorily the visually presented test material. The Verbal IQ was not assessed because of the patient's aphasia.

Examination for ideomotor apraxia on March 31st
Table I summarizes the patient's performance in the symbolic and nonsymbolic tasks for ideomotor apraxia. For each performance 10 tasks were
given. The total number of tasks for ideomotor apraxia was 200. The
percentage of tasks correctly solved is given in the table. The patient
evidently had only a moderate bilateral ideomotor _llpr~?C!a__ _<?!~()th _arm~
~~ legs.
TABLE I

Results of Examination for _Ideomotor Apraxia
On imitation

On verbal command

Symbolic movements
right arm
left arm
both hands
right leg
left leg

60 %
80 %
80 %
90 %
80 %

40%
60%
60%
70 %
80 %

Non-symbolic movements
right arm
left arm
right leg
left leg

70 %
80 %
100 %
80 %

80%
80 %
90 %
80%

Oral apraxia tasks

60%

70%

Task

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Klaus Poeck and Gerd Lehmkuhl

Examination for ideatory apraxia on April 3rd

The patient was requested to perform a number of sequential actions
requiring the use of various objects placed, separately for each of the
tasks, in front of her. These tasks, together with the patient's performance,
are described in the following (see Poeck and Lehmkuhl, 1980).
Hanging a picture on the wall. A picture, a nail and a hammer were
placed in front of the patient. The patient commented adequately on the
task and approached it without hesitation. She first tried to fix a tag on
the picture although there was already one there. She then took the nail
and pushed it through the tag, remarking: "It goes like this". She did not
make use of the hammer and kept on pushing the nail through the tag.
Only when the examiner indicated that there was a hammer at hand did
she take it and try to hit the nail into the wall while the picture was
hanging on the nail.
Telephoning. A telephone book and a telephone were in front of the
patient. She first leafed over several pages of the telephone book. The
examiner then pointed to the telephone. She turned the dial without lifting
the receiver. She lifted the receiver after having dialled.
Putting butter and marmalade on a slice of bread. The patient had no
difficulties performing the task.
Punching several sheets of paper and then putting them in a loose-leaf
folder. Paper, a folder and a paper-punch were in front of the patient.
The patient said: "The paper has to be put in there," and pointed to the
folder. She took the sheets of paper in her hand and opened the folder.
She stopped helplessly. When shown the paper-punch she correctly punched one sheet and put it into the folder, without making use of the two
holes she had just made. After being corrected she was able to perform
the task but immediately afterwards she took another sheet of paper and
put it directly into the fold~r, without punching it.
Preparing a cup of coffee. A pot of water, a cup, a spoon, a jar of
Nescafe, and a water immersion-heater (familiar object for Germans) were
placed in front of the patient. The patient grasped the water immersionheater and remarked: "I have to prepare coffee." After making several
helpless movements with the heater the patient took the plug, put it into
the water pot and stirred around with it. With a helpless expression on her
face she said: "It does not work like this." For a moment she did not
move at all. When the examiner pointed to the socket, she answered:
"Well, that's it." It was only after several trials, however, that she managed to plug in the heater. Then she took the water immersion-heater again
and did not know what to do with it. She aimed at the cup, hesitated,

Ideatory apraxia in a left-handed patient

279

and then correctly put it into the water pot. She opened the jar of Nescafe,
but she did not know what to do with the coffee. She made a movement
with the jar in the direction of the water pot and looked inquiringly at the
examiner saying: "I know, that's not it," and she started to put the coffee
into the cup. She did not use the spoon although she was told that there
was one. She then took the spoon and stirred the coffee in the cup with
no water in it.
Opening a tin. A tin, a tin opener, a spoon and a pot were in front of
the patient. On seeing these objects the patient remarked: "To prepare a
soup." She took the tin in her hands, turned it around and said: "Can be
opened." But she continued to hold the tin in her hand until the examiner
pointed to the tin opener. She then took the tin opener; however instead
of using it properly, she beat on the tin with it several times. Only with
the aid of the examiner did she manage to use the opener properly. She
then stirred around in the tin with the spoon. After the pot was placed
near her she started to spoon small portions of the peas into the pot (with
a stirring spoon).
Arrangement of photographs showing segments of a sequential action.
A test was developed to further investigate the patient's ability to organize
correctly a sequential action (Lehmkuhl and Poeck, in press). The test consists of a series of tasks similar to the ones just described. However,
instead of having the patient actually perform the actions, the entire series
of events is represented on 5 - 7 photographs which show the single steps
leading to the final result. The first photograph showed all the objects
used in the task. The patient was requested to put these pictures in the
correct order. Table II summarizes her performance. Again, her comments
indicated that she recognized the objects.
TABLE II

Performance in the Task of Arrangement of Photographs
(logical sequence = 1 - 4, 1 - 5 or 1 - 6, respectively)

Task

Sequence of steps as indicated by the patient

Putting on a coat
Preparing coffee
Putting butter on bread
Telephoning
Putting on shoes
Punching paper
Opening a can
Hanging up a picture
Brushing teeth

1
1
1
1
1
1
1
1
1

3
3
3
2
2
6
2
3
2

2
4
4
3
4
3
3
2
5

5
2
2
5
3
4
5
4
4

4
5
6
4
5
5
4
5
3

7
5
6
6
2

6

6

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Klaus Poeck and Gerd Lehmkuhl

Putting together a puzzle. A further examination showed that the
patient's impaired performance was not due to an inability to recognize
(and imagine) objects visually. She was given five puzzles (a snake, a
locomotive, a light bulb, a house, and a car). She succeeded to put the
parts together with no difficulty.
Non-verbal vs. verbal processing oj serial tasks

The patient was given a test in which she was required to order 6
pictures in such a way that a story resulted. The test (Huber, 1978)
comprised nine such series of pictures. Besides having to order pictures
the patient was also requested to order series of 6 sentences in such a
way that a coherent text resulted. These sentences corresponded to the
individual pictures in the mentioned picture ordering task. For each picture
story there were two sets of sentences: in one set the six sentences were
long and cohesively bound, in the other set they were short and had no
cohesion. There was a total number of 27 tasks (3 X 9). In each of the
27 tasks the patient could achieve a maximum error score of 5 points.
The results are given in Table III.
TABLE III

Performance in Non- Verbal versus Verbal Processing of Serial Tasks

Pictures
Short, non-cohesive sentences
Long, cohesive sentences

Error points

Possible error points

18
3
2

45
45
45

DISCUSSION

Ideatory apraxia is defined here, following Pick (1905), Liepmann
(1908), Ajuriaguerra, Hecaen and Angelergues (1960) and Zangwill (1970)
as a neuropsychological syndrome where brain damaged patients are
unable to carry out a series of actions requiring the use of various objects
in the correct sequence necessary to achieve the desired goal. The following
types of errors are observed: The logical sequence of single movements
is not respected, i.e. objects are improperly used, or single movements
constituting the action are skipped or repeated in a perseveratory manner.
As mentioned in the introduction, the faulty use of a single object in
a single movement (Morlaas, 1928; Ajuriaguerra et aI., 1960; Ajuriaguerra
and Tissot, 1965) is not sufficient for the diagnosis of ideatory apraxia.
This behaviour, in our view, is either indicative of a severe degree of

Ideatory apraxia in a left-handed patient

281

ideomotor apraxia where even the presence of an object is not able to
evoke the correct movement or it demonstrates erroneous recognition of
objects.
In our experience, even grossly incorrect performances still have some
relation to the target action. We have not observed - neither in this case
nor in other patients with ideatory apraxia - the behaviour described
sometimes in the older literature (Pick, 1905; Nielsen and Ives, 1936;
Nielsen, 1946) where patients carry out movements having no relation at
all to the target action, like in the classical example described by Pick,
where a patient bites into a piece of soap. In contrast to such cases of
severe behavioural disturbance the patients we diagnose as having ideatory
apraxia are able to name or describe the target action and the objects
necessary, including those which they use improperly.
Most of the patients with ideatory apraxia, if not all, are aphasic.
However, the reverse is not the case, only few aphasic patients have
ideatory apraxia (Ajuriaguerra et aI., 1960; De Renzi et aI., 1968). The
aphasia, as a rule, is of the Wernicke or global subtype. A high degree
of severity of aphasia is no prerogative for the occurrence of ideatory
apraxia (Ajuriaguerra et aI., 1960; De Renzi et aI., 1968). No intrinsic
relationship between the linguistic features of the aphasic syndrome and
the movement disorder can be concluded. We agree with De Renzi et aI.
(1968) that the presence of aphasia merely indicates a posterior lesion in
the hemisphere dominant for language.
Our patient H.G. had Wernicke's aphasia in the first period of her
illness. The aphasia, however, improved rapidly and was only very mild
at a time where idea tory apraxia was still clearly demonstrable (see her
good communicative performances, as evidenced by a Goodglass-Kaplan
severity rating of 4). Ideatory apraxia therefore cannot be considered a
language dependent disturbance in our patient. The improvement of aphasia in the presence of a persisting brain lesion suggests that in this patient,
like in many other left-handers, language had a bilateral hemispheric
. .. .
. ----.
representktion.
--Theassurllption of a disconnection syndrome does not appear plausible because idea tory apraxia was present with visual as well as somesthetic input. A disconnection mechanism (Geschwind, 1965) under these
conditions would imply that in this case there was an extensive watershed
lesion, as in the syndrome of isolation of the speech area (Geschwind,
Quadfasel and Segarra, 1968). This syndrome, however, was not present
in our case, neither clinically nor anatomically. The ideatory apraxia was
in no way dependent on ideomotor apraxia. The ideomotor (limb and
oral) apraxia, which was initially present in our case, had cleared very
rapidly, quite similar to the Wernicke aphasia.
There remains the question whether ideatory apraxia in this case was

282

Klaus Poeck and Gerd Lehmkuhl

the consequence of a visual cognitive disturbance. We would not accept
this hypothesis, because the patient was able to grasp the situation of the
task immediately and to verbalize it. She recognized the single objects
correctly, she named them and described the individual actions required
to perform the whole sequence. She also showed good performance in
the task of putting together jigsaw puzzles.
Several authors have put forward the question whether ideatory apraxia
is the consequence of an overall intellectual deficit (Nielsen and Ives,
1936) or of a defective conceptual process (Denny-Brown, 1968). Some
of the case descriptions by Pick and Liepmann might in fact suggest this
assumption. Our patient was given the German version of the Wechsler
Intelligence Test. Since she had a mild aphasia, we wanted to avoid a bias
due to the language deficit. Therefore only the performance 10 was tested.
The value of 74 points is clearly below normal. The patient's behaviour
on the ward and during the examinations, however, gave clear evidence
that she was not severely demented.
In our view, the basic disturbance in our patient was the inability to
combine various movements into a purposeful sequential action. This deficit
was apparent in three different situations:
(a) handling of objects in the above descrived test situations,
(b) placing pictures representing segments of sequential actions in
correct order, and
(c) arranging pictorial representations of stories, each consisting of
six individual drawings.
The term "agnosie de l'usage" (Morlaas, 1928) does not appear to us
appropriate for the behavioural deficit in ideatory apraxia. It is true that
some aspects of these patients' behaviour suggest that they do not know
how to use the objects in question. There are many other errors however
which cannot be adequately explained on this basis. Frequently the patient
fails just because of a sequential error, sometimes the same action is
executed once correctly and then incorrectly, and, finally, quite often the
patients are able to describe verbally or to indicate by gestures that they
are aware of the use of the objects. The sequential deficit could be demonstrated also in tasks where no actual use of objects was required.

ABSTRACT

A case is described of a left-handed patient with a circumscribed right-sided
posterior brain lesion, who presented with a neuro-psychological syndrome of
Wernicke's aphasia, ideomotor and idea tory apraxia. The aphasia and ideomotor
apraxia cleared within 10 days, while ideatory apraxia persisted. Ideatory
apraxia therefore was not dependent on the language disorder, nor was it related

Ideatory apraxia in a left-handed patient

283

to ideomotor apraxia. On the basis of various neuropsychological examinations,
the nature of the apraxic movement disorder in this case is discussed. To our
knowledge, this is the first case of ideatory apraxia with right-sided brain damage described in the literature. A particular feature of this patient is that obviously
language and the motor functions underlying performance in tests for ideomotor
apraxia had a bilateral hemispheric representation whereas a unilateral lesion
was sufficient to bring about persistent ideatory apraxia.

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